Part 3: Practical Frailty Testing

Nicola Broadbent

Auckland City Hospital

First things firstI am not a geriatrician

I am an anaesthetistI work full time in public in Auckland, NZ

I did about a year of geriatrics at registrar level (inpatient and community) about 15 years ago prior to training in anaesthesia

I have regular sessions in an anaesthetist led anaesthetic assessment clinic which includes a high risk assessment arm (and a lot of older frail patients)

This is my (anaesthetic) take on how we could apply frailty in our perioperative environment

Intent of this session

Quick overview of frailty and what has been covered so far in this meeting

Explore how anaesthetists could consider screening for frailty in a time poor anaesthetic clinic

Introduce how to conduct a selected number of tests

Perioperative frailty

“Frailty” is a fashionable word in perioperative circles

Frail people undergoing surgery are at increased risk ofDeathInstitutionalisationPostoperative mortality and morbidity

As an anaesthetist in a preoperative clinicHow do I measure It?

Overview of frailty

No consensus definition

Accepted as a physiological state where a person is vulnerable to external stressors

2 main theoretical concepts of frailty around which testing is anchored

Phenotype of frailty

Accumulation of deficits

Phenotype of frailtyBased on article by Fried et al where they used the US Cardiovascular Health Study data to test a theoretical concept.

Developed the 5 Fried criteriaShrinking

Unintentional weight loss of >10 lbs (4.5kg)

WeaknessGrip strength lowest 20% by gender and BMI

ExhaustionSelf reported

Slowness15 ft (4.5m) walking time lowest 20% by gender and height

Low activitySelf reported

Comorbidity and disability ≠ frailty

Frailty by deficit accumulationConcept proposed by Rockwood and Mitnitski

As people age they accumulate deficits.

Rate and deficits vary between people

Frailty index counts deficits and generates index.

Deficits counted usually in the order of 40-80

Can be gained from a comprehensive geriatric assessment (CGA)

Rockwood & Mitnitski

Why test frailty in the perioperative setting?

Risk stratification?additive information to ASA and comorbidity

Identification of factors for potential modificationThose who may benefit from a comprehensive geriatric assessment

Enable intervention from a geriatric/older peoples service

Anyone in the audience measure frailty routinely preoperatively?

Administering a test in the anaesthetic clinic environment

If we administered a frailty screen to all elderly patients how long do you think is acceptable for this to take?

<5 minutes

5-10 minutes

10-20 minutes

>20 minutes

What options are out there?Systematic review in 2011 identified 20 frailty instruments.

8 domains of which only the frailty index covered all.Nutritional statusPhysical activityMobilityEnergyStrengthCognitionMoodSocial relations/Social Support

Performance based measures (PBM)A performance based test may be useful as it also informs clinician about actual functioning

Questionnaires

Combinations of PBM and questionnaires

Ideal perioperative frailty test

Easy to administer by non-geriatricians

Quick and easy to calculate

Highly predictive of complications, mortality and level of care

Many of the options appear unfeasible due to time required

British Geriatric Society “Fit for Frailty” 2014 guidelines Recommended Gait Speed and Edmonton Frail scale for potential perioperative use

Tests covered

Performance based measures

Slow gait speed

Timed Up and Go (TUG) Test

Phenotype scales (modified Fried criteria)

Edmonton Frail Scale

For each test I will cover

The test

Description

Demonstration for performance based measuresGait speed

Timed up and Go test

Evidence in perioperative settings

Gait speed

Patients normal gait speed measured over a distance between 4-10 metres

Usually 4, 5, or 6 metres.

Patients walks at normal pace across a measured distance

Patient can use normal walking aids

Demonstration from YouTube

Sourced from PaulPotterPT

Setting up the test

Measure out distance.

Allow 2 metres before 0 metre line to allow patient to “get up to speed”

Start stopwatch at first footfall after 0 metre line

Stop stopwatch after the first footfall over the end distance.

Allow 2 metres after end distance to slow down

Repeat 2-3 times and record average

How long do you think this should take in a healthy person?

<2 seconds

2-3 seconds

4-5 seconds

>5 seconds

Lets have a go!

Perioperative evidence for gait speed

Often part of a larger frailty score

Recommended by British Geriatric Society for perioperative use in their “Fit for Frailty” guidelines

Evidence in cardiac surgical patients

Afilalo et al 2010 and Afilalo et al 2012

131 patients >70 years undergoing cardiac surgery

4 university affiliated hospitals in US and Canada

Measured 5m gait speed

Slow defined as >6 seconds

Independent predictor of mortality

OR 3.17 (1.17, 8.59) along with age > 80yr and repeat cardiac surgery

Independent predictor of discharge to a health care facility

OR 3.19 (1.40, 8.41) along with age >80 year

152 patients > 70 years undergoing cardiac surgery

Same cohort source (4 university affiliated hospitals in US/Canada)

Looked at 4 frailty scales5-item Cardiovascular Health Study (CHS) frailty scale (Fried)7 item expanded CHS scale (5 + cognitive impairment and depressed mood)4 item MacArthur Study of Successful Aging frailty scale

gait speed, handgrip strength, inactivity, cognitive impairment

5 m gait speed.

Single measure of gait speed had superior predictive ability to other frailty scalesOR for mortality and increased morbidity 2.63 (1.17, 5.90)AUC 0.64

Circ Cardiovasc Qual Outcomes 2012. 5:222-228.

Timed Up and Go test (TUG)Time taken to

Get up out of a chair (standard height with arms)

Walk 3 metres

Return and sit down again

Start stopwatch when you say “Go”

Stop stopwatch when patient buttocks touch the chair

Do an average of 3 times

How long do you think this should take in a healthy person?

<5 seconds

5-10 seconds

10-15 seconds

>15 seconds

TUG test video from the CDC

Viewable on YouTube

Lets have a go!

Evidence for perioperative TUGOnly 1 study that specifically examines TUG (but it is included in other scales)

272 patients >65 years undergoing colorectal and cardiac operationsSingle centre DenverVA hospital (98% male cohort)

Compared a slow group to combined fast and intermediate groupFast TUG test <10secondsIntermediate TUG test 11-14 secondsSlow TUG test >15 seconds

Higher rate of complications

Higher rate of institutionalisation

Increased 1yr mortality

Cumulative survival stratified by TUG test

Cardiac surgical population in Norway

213 patients > 74 years followed up 1 yr after surgery.

Looked at a number of itemsChair rise

Not strictly a TUG test. “Patient is asked to get up and down from a chair 3 times and time is measured”

Self reported weaknessStair climbClinical Frailty ScaleCreatinine

Chair rise most predictive of 1 year mortality.

Cut-offs for Performance Based Measures in the perioperative literature

Gait speed

5m >6 seconds (Afilalo 2010, Afilalo 2012)

15 ft >6 seconds for women >159cm or men >173cm (Hopkins Scale)

15ft >7 seconds for women <159 cm or men <173cm. (Hopkins scale)

TUG test

Slow >15 seconds (Robinson 2013)

EFS uses 11-20 seconds as 1 point, 20 seconds as 2 points

Edmonton Frail ScaleCombination of 9 measures

1 Performance based measureTimed up and Go Test

1 Cognition testClock draw

7 Questions exploring frailty domains

Validated for use in non-geriatricians

Available as a free app for iOS and Android

Edmonton Frail Scale

Rolfson et al 2006. Age and Ageing. 35(5): 526-529 [research letter]

Perioperative evidence for EFS

125 pt >70 years undergoing non-cardiac surgery (82% lower limb orthopaedics)

Edmonton Frail Scale Assessment in preoperative surgical clinic

OutcomesPostoperative complications

Length of stay

Inability to be discharged home

Age and EFS score independently associated with postoperative complications, discharge to institution and prolonged LOS

Key findingsEFS < 4 and EFS >7 had clinical predictive utility

Unclear what to do with intermediate scores (EFS 4-7)

EFS of 3 or less had a lower risk of complication and higher chance of being discharged home.

Complication OR 0.27

80% discharge home

EFS >7 had a higher risk of complication and a lower chance of being discharge home

Complication OR 5.02

40% discharged home

Frailty phenotype

Lots of modifications of Frieds criteria for frailty.

2 studies report the Hopkins Frailty Score

Makary 2010 (Fried as co-author), Revenig 2013

Essentially the Fried phenotype.

1. Weight loss

2. Hand grip strength

3. Self reported exhaustion

4. Self reported activity

5. Gait speed

Fried phenotype

596 patients >65 yr presenting to John Hopkins over 1 year period for elective surgery

10.4% frail (4-5 on Hopkins Scale)31.3% intermediately frail (2-3 on Hopkins Scale)

Outcomes30 day complications

OR 2.06 intermediate frail, OR 2.54 frail

Length of StayDischarge deposition

Risk of being discharge to skilled/assisted careOR 3.16 intermediate frail, OR 20.48 frail

J Am Coll Surg 2010. 210: 901-908.

189 patients >18 years undergoing major intra-abdominal urological, general or oncologic surgery.

Collected preoperative variables including Hopkins Frailty Score3.7% frail, 22.8% intermediately frail

Primary outcome 30 day complications38.6% suffered at least 1 complication

Only composite frailty score predictive of postoperative complication OR 2.05Also examined ASA, Katz (ADL), CES-D (depression), Charlson comorbidity score, albumin, CRP, eGFR, Hb

J Am Coll Surg 2013. 217:665-670.

Resources required for tests describedGait speed

StopwatchMeasured distance

TUG testStopwatchChairMeasured distance

Edmonton Frail ScaleApp or paper scalePaper and pen for a clock drawResources for TUG test

Fried phenotype scalePaper scaleHand dynamometerResources for gait speed test

Problems with frailty testingEveryone has had a go at making up their own test or does different versions of the same test

The perioperative literature is messy

When to do itPreoperative anaesthetic clinic?Surgical clinic?

What to do with the patient who can’t perform a performance based measure

Cut-offs for frailtyWhat to do with the poor scoring patient

?Refer to geriatric service?Defer surgery?Negotiate different surgery

A large number of patients in frailty studies with performance measures can not complete and therefore we have missing data in the most frail or ill.

Using the Canadian Study for Successful Aging, Rockwood et al showed that if you can’t complete a performance based measure you have a poor outcome (49.3% couldn’t complete)

Take home:

Failing to perform a PBM is BAD NEWS

Rockwood et al 2007. Age and Aging. doi 10.193/ageing/afl160

How should we use frailty testing in our practice?

The floor is open for discussion and comment